Women treated for gynecological cancer are often affected by pain during sexual intercourse, namely dyspareunia. Despite the negative impact of this condition on women’s quality of life, only a few treatments with limited supporting evidence have been proposed in clinical practice guidelines [1]. A recent prospective interventional study has investigated a multimodal pelvic floor physiotherapy (PFPT) treatment in a cohort of women affected by dyspareunia following gynecological cancer [2]. The results suggested significant improvements following treatment, such as a reduction in pain as well as an improvement in sexual function, pelvic floor muscle function (i.e., reduction in muscle tone and increase in tissue flexibility and contractile properties) and psychosexual outcomes (e.g., increase in self-efficacy) at post-treatment, which were maintained at 12-month follow-up [3]. These promising effects indicate that women could benefit from this treatment as part of cancer survivorship care. However, data informing us on whether multimodal PFPT could be implemented in healthcare settings are scarce. Acceptability is a key component in the development and implementation phases of complex treatments. This multifaceted construct reflects the extent to which patients consider a treatment to be appropriate. Data relating to the acceptability of multimodal PFPT treatment in gynecological cancer survivors with dyspareunia are limited to women’s adherence to home exercises (88%), the attendance rate at treatment sessions (93%), and the average satisfaction rate (93%) assessed at post-treatment [2]. Careful consideration of patients’ views and experiences provides the best opportunity to deepen our understanding of treatment acceptability and to optimize the treatment in healthcare settings. Therefore, the aim of this study was to explore the views and experiences of gynecological cancer survivors with dyspareunia regarding the acceptability of a multimodal PFPT treatment.

This qualitative study followed the study that investigated a 12-week multimodal PFPT treatment in a cohort of gynecological cancer survivors with dyspareunia. The multimodal PFPT treatment consisted of 12 weekly individual 60-min sessions, free of charge. The treatment was delivered in person by a physiotherapist with expertise in pelvic and women’s health. The treatment comprised education, myofascial release techniques, pelvic floor muscle exercises with biofeedback, and home exercises, including the use of a vaginal dilator. The treating physiotherapist also provided support to women for resuming pain-free sexual intercourse. After completing their participation, women were invited to take part in an individual telephone interview conducted by a physiotherapist not involved in the treatments. Interviews were carried out at 12-month follow-up, allowing the participants to take a step back from the treatment and provide critical insight on treatment acceptability in the long term. The interview guide was constructed based on the framework of acceptability proposed by Sekhon et al. (2017). All interviews were recorded and transcribed for analysis. An inductive approach was adopted where codes are applied to key ideas which give form to emerging themes. The research team members responsible for interviewing and coding the transcriptions were blinded to the participants’ treatment response. Coding disagreements were discussed until a consensus was achieved. The research team reviewed the codes during meetings.

Of the 31 women who participated in the multimodal PFPT treatment, 28 (90%) accepted to take part in the interviews at 12-month follow-up. One woman withdrew for family reasons, one was lost at follow-up, and one woman was not available. No significant difference in participant characteristics or treatment response was found between those who participated and those who did not participate in the interviews. At baseline, the mean age of our cohort was 55.9 (SD 10.8) years and the mean body mass index was 28.5 (SD 5.3) kg/m2. Women were diagnosed at various cancer stages and received different oncological treatments: 24 (77%) had surgery, 19 (61%) had brachytherapy, 15 (48%) had external beam radiation therapy, and 16 (52%) had chemotherapy. At 12-month follow-up, three women indicated that they had cancer recurrence or another cancer, and one woman had a severe upper urinary tract infection. Participants confirmed that they did not undertake other treatments during the 12-month follow-up period.

Our cohort described the acceptability of multimodal PFPT according to three main themes. Figure 1 shows the relationship between the themes. Theme 1: Appropriateness of treatment characteristics. The participants reported that the treatment was acceptable given the relevance of the multimodal PFPT treatment characteristics for reducing dyspareunia. They indicated that the choices in treatment modalities, healthcare provider (physiotherapist), care delivery (in person), and treatment intensity were appropriate. Theme 2: Balance between participation and treatment effects. Women explained how the treatment characteristics, along with their beliefs, attitudes, and awareness of the treatment effects, motivated their participation and their efforts to fully adhere to the treatment. Although a few women perceived the treatment intensity as demanding in terms of participation, they all emphasized that it was crucial in achieving significant improvements. Theme 3: Satisfaction. Given their positive experiences with the treatment characteristics and the balance between their efforts and the results they obtained, all women expressed being highly satisfied with the treatment. As a result, all participants recommended this treatment.

This is the first study to examine the acceptability of multimodal PFPT for treating women affected by dyspareunia after gynecological cancer. The findings of this qualitative study suggest that multimodal PFPT is acceptable according to gynecological cancer survivors with dyspareunia. The results highlight the importance of selecting the appropriate treatment modalities, healthcare provider, care delivery, and treatment intensity in healthcare settings. Interestingly, although the participants described the intensity as being the principal inconvenience of multimodal PFPT, all women stressed that it was crucial in obtaining satisfying outcomes. The participants also reported that the effects they perceived were related to their participation in the multimodal PFPT treatment. Efforts could therefore be made to alleviate women’s perception of burden related to the treatment intensity and to increase their participation. For instance, the underlying mechanisms of dyspareunia related to cancer and oncological treatments and how multimodal PFPT is relevant could be described to women. Explaining how their participation is important in reaching satisfying outcomes could be emphasized. Highlighting the changes throughout the treatment could also encourage women’s participation. Given our cohort’s positive views and experiences of multimodal PFPT, it is not surprising that all participants recommended this treatment.

Multimodal PFPT treatment was deemed acceptable by women affected by dyspareunia after gynecological cancer. The results provide a deeper understanding of what makes this treatment acceptable to women, namely the appropriateness of treatment characteristics, the balance between participation and treatment effects, and satisfaction. Our work also identified several aspects that should be considered in the implementation stage. The findings of this study can serve as a basis for multidisciplinary teams and decision-makers to successfully implement multimodal PFPT to improve the pelvic health of women in gynecological cancer survivorship care.

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Cyr MP, Dumoulin C, Bessette P, Pina A, Gotlieb WH, Lapointe-Milot K, Mayrand MH, Morin M. Feasibility, acceptability and effects of multimodal pelvic floor physical therapy for gynecological cancer survivors suffering from painful sexual intercourse: A multicenter prospective interventional study. Gynecol Oncol 2020;159:778-784.
Cyr MP, Dostie R, Camden C, Dumoulin C, Bessette P, Pina A, Gotlieb WH, Lapointe-Milot K, Mayrand MH, Morin M. Improvements following multimodal pelvic floor physical therapy in gynecological cancer survivors suffering from pain during sexual intercourse: Results from a one-year follow-up mixed-method study. PLoS One 2022;17:e0262844.

Continence 2S2 (2022) 100355
DOI: 10.1016/j.cont.2022.100355